Vital Signs and Assessments
This vital sign measures the force of blood against the walls of the arteries.
What is Blood Pressure?
Before using a newly inserted NG tube for feeding or medication administration, placement must be verified using these two methods.
What is a ph assessment and chest xray?
A suction pass should generally be limited to approximately this amount of time and number of passes.
What are 10 seconds and 3 passes?
This is the best method to prevent infection.
What is Hand Hygiene?
This drainage is thin, watery, and pink because it contains both serum and blood.
What is serosanguineous drainage?
This assessment technique involves listening to internal body sounds, such as bowel and lung sounds.
What is Auscultation?
During a male sterile Foley catheter insertion, the catheter is inserted into the urethra and urine begins to flow. The student immediately inflates the balloon. What did the student do wrong, and why?
what is advance it further to the bifurcation because inflating the balloon while it is still in the urethra can cause serious urethral injury?
A patient needs a precise, controlled FiO₂. This device is the best choice.
What is a Venturi Mask?
What are the correct steps in order when opening a sterile field?
Side flaps
Flap away
Flap closest to body
1) Flap away
2) Side flaps
3) Flap closest to body
You have to apply sterile gauze with sterile saline during this medical emergency.
What is an evisceration? An abdominal incision opens and internal organs protrude through the wound.
This is the correct sequence of performing an abdominal assessment.
What is RLQ, RUQ, LUQ, LLQ?
The surgical opening created to allow stool or urine to leave the body is called this.
What is a stoma?
This type of oxygen device prevents CO2 from re-entering the lungs.
What is a non-rebreather?
Name two diseases that require a patient to be on airborne precautions? (N95 , negative pressure room, gown, googles, gloves).
Varicella, Tuberculosis, Measles
These two common postoperative drains use closed-suction drainage.
What are Jackson-Pratt and Hemovac drains?
When assessing a patient's pulse, the nurse should assess/document these 3 things.
rate, rhythm, and strength (amplitude)
Before NG tube placement, what are the three important things a nurse should assess.
What is recent facial trauma/surgery, ability to swallow, and nasal patency/deviated septum?
This device helps prevent atelectasis and pneumonia on patients.
What is an incentive spirometer?
True or False: You can use Sani Cloth Germicidal (Purple) Wipes to clean equipment use in a patient with contact/enteric precautions?
False: You can ONLY use Sani Cloth Disinfectant (Yellow) Wipes. It contains bleach that kills microorganisms such as C-diff.
Patient is alert and oriented x3 (disoriented to place) , has mild tremors on the hands, and diaphoretic.
What is hypoglycemia?
You obtain these vital signs:
The patient is pale and short of breath.
Which finding is the priority concern?
What is Airway, Breathing, and Circulation?
What are the correct steps in order?
attach new pouch
remove old pouch
document
cut skin barrier
assess stoma
verify seal
clean stoma and surrounding skin
5. attach new pouch
1. remove old pouch
7. document
4. cut skin barrier
3. assess stoma
6. verify seal
2. clean stoma and surrounding skin
A newly placed tracheostomy becomes accidentally dislodged. What device should the nurse use to prevent closure of the stoma?
What is an obturator?
Identify the precaution:
No fresh fruits/vegetables/flowers
No sick contacts
Level 3 mask upon entering room
What is Neutropenic precautions?
Patient is hyperglycemic (600), you administered regular insulin. Now patient is complaining of muscle cramps in the legs and palpitations.
What is hypokalemia? - Insulin helps draw glucose from the bloodstream into the cells for energy but also potassium.